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Women and HCV

by Liz Highleyman
Contributing Editor

In the past decade, chronic hepatitis C has become a widespread health concern, and this is true for women as well as for men. The U.S. federal government estimates that about four million Americans are infected with hepatitis C. More men than women have the disease; most experts believe this is because men are more likely to have risk factors for exposure to the hepatitis C virus (HCV), not because they are more susceptible than women to infection. In the U.S., African-Americans and Latinos have higher hepatitis C rates than whites.

Many people remain unaware that they have HCV. Before 1992, people often contracted HCV through blood transfusions. In 1992, an accurate test for donated blood came into wide use, and today transfusions are considered safe. In the 1970s and 1980s, before HCV was identified, women often received blood transfusions when they underwent Cesarean delivery (C-section); some of these women remain unaware that they received donated blood. Some experts suggest that women who had a C-section before 1992 should be tested for HCV.

HCV Risk Factors

The risk factors for contracting HCV are similar for women and men. Sharing needles for injection drug use is a major risk, and most studies show that a majority of people who have injected drugs are HCV-positive. Nurses and others who work in healthcare settings may contract HCV when they come into contact with blood, for example through accidental needlesticks. Other methods of transmission include shared equipment used for non-injection drugs (for example, cocaine straws and crack pipes); re-use of needles for acupuncture, tattooing, or body piercing; and shared personal items such as razors, manicure tools, and toothbrushes. Be sure to cover any cuts or sores to prevent contact with blood, and properly dispose of used tampons and sanitary napkins. Hepatitis C is not spread through casual contact such as sneezing, coughing, hugging, or sharing drinking glasses. For as many as 10% of people with HCV, no specific risk factors can be identified.

Sexual Transmission of HCV

Sexual transmission of HCV is uncommon. Most studies show that only a small percentage of people – estimated at 0-3% -- contract HCV through unprotected heterosexual intercourse with a steady, monogamous HCV-positive partner. People who have multiple sex partners have a higher risk of contracting HCV. According to the National Institutes of Health (NIH), people in long-term, monogamous relationships do not need to change their current sexual practices, although they should discuss safer sex if either partner is concerned about transmission. The NIH recommends that people who have multiple sexual partners should practice safer sex, in particular using latex condoms. There are no known cases of HCV being transmitted through oral sex on a woman (cunnilingus) or on a man (fellatio); however, it is theoretically possible that the virus could be transmitted this way if a person has mouth sores, bleeding gums, or a throat infection. Some studies indicate that sexual transmission from men to women is more efficient than transmission from women to men, as is also the case with HIV. As with HIV, HCV may be more efficiently transmitted through anal sex than through vaginal intercourse. The risk of HCV transmission through woman-to-woman sexual activity has not been studied. Because HCV is spread through blood, it is more likely to be sexually transmitted when a woman is having her menstrual period.

HCV Progression & Symptoms in Women

Various studies have shown that hepatitis C progression is slower and liver damage tends to be less severe in women than in men. For one thing, it appears that women are more likely to completely clear HCV from their bodies after infection and never develop chronic disease. It is usually estimated that 80-85% of all people infected with HCV will go on to develop chronic hepatitis C, but the rate is lower for women. A German study of 1,018 young women infected with HCV in 1978-9 through contaminated immunoglobulin transfusions found that after 20 years, about 45% had cleared the virus. Researchers do not know why the HCV clearance rate is higher in women than men.

Women who do have chronic hepatitis C (that is, they still have HCV after six months) tend not to develop liver cirrhosis (scarring), liver cancer, or liver failure as rapidly as men. For all people with chronic HCV, disease progression is usually slow. A majority of people with chronic hepatitis C never develop serious liver damage. Among those who do, the process usually takes years or even decades; the usual estimate is 10-40 years, and may be longer for women. In the German study, only four of the 1,018 women had developed cirrhosis after 20 years. Some experts believe that the female hormone estrogen protects women from liver damage; if this is the case, the protective effect may diminish after menopause, as women’s bodies produce less of the hormone.

Many people with HCV have no symptoms and lead normal lives. Those who do develop symptoms may experience prolonged fatigue (tiredness), fever, headache, loss of appetite, nausea, pain in the abdomen, or pain in the muscles or joints. The types of symptoms are similar in women and men, but women may develop symptoms later or may experience more mild effects.

Several autoimmune conditions, in which the immune system attacks the body’s own tissue, are associated with HCV (for example, cryoglobulinemia, glomerulonephritis, and Sjogren’s syndrome). Because women in general are much more likely than men to have autoimmune conditions, it is not surprising that women with HCV seem to be at greater risk than HCV-infected men for developing these conditions. However, according to Norah Terrault, MD, MPH, of the University of California at San Francisco Division of Gastroenterology, while women with HCV may be more predisposed than men to autoimmune conditions, this does not necessarily mean that these conditions are directly associated with HCV; women may simply be more likely to have co-existing autoimmune conditions that may not be caused by HCV. More study is needed in this area.

HCV Diagnosis & Monitoring

Doctors use various tests to determine if a person has hepatitis C. One type of test measures antibodies in the blood, indicating that a person been exposed to HCV; the two most common antibody tests are called ELISA and RIBA. Viral load tests measure how much HCV genetic material is present in the blood; the two most common viral load tests are called PCR and bDNA. There are several different types of hepatitis C virus called genotypes. Genotype tests can help determine how well HCV treatment might work. Genotypes 1a and 1b, which are most common in the U.S., are more difficult to treat. Current research does not indicate that women are likely to have different HCV genotypes than men.

Liver function tests, which measure levels of liver enzymes and other substances in the blood, indicate how well the liver is working. Changes in liver enzyme levels can help to determine whether the liver is damaged and whether HCV treatment is working. People with chronic hepatitis C often have increased levels of two liver enzymes called ALT and AST. Women tend to have lower ALT levels than men. However, this does not necessarily means that their liver disease is less severe. According to Terrault, ALT is “not a perfect reflection” of liver damage, and screening tests based on ALT levels alone may miss some women with liver disease.

HCV Treatment in Women

Not everyone with hepatitis C needs treatment. Doctors determine whether treatment is appropriate based on various factors including HCV genotype, viral load, liver enzyme levels, and extent of liver damage. Since women tend to have less severe liver damage that develops more slowly, they may be less likely than men to need treatment. However, treatment recommendations should not be based solely on ALT levels, which are typically lower in women.

Today, the current standard treatment for chronic hepatitis C is a combination of two medications, interferon and ribavirin. Interferon is a manufactured version of a natural substance produced by the body's immune system. Ribavirin (brand name Rebetol) is an antiretroviral drug that kills certain types of viruses. Combination treatment with interferon plus ribavirin was approved by the Food and Drug Administration (FDA) in 1998. Studies have shown that the combination works better than treatment with interferon alone (monotherapy). But interferon monotherapy does appear to work well for some people with mild hepatitis who have minimal liver damage. Recent studies have shown that a new type of interferon -- called pegylated interferon -- works better with ribavirin than standard interferon. Pegylated interferon lasts longer in the body and does not have to be injected as often. This August, the FDA approved the combination of pegylated interferon plus ribavirin for the treatment of chronic hepatitis C. The standard treatment regimen for HCV is the same for women and men.

Since HCV treatment works best in people with milder liver damage, women tend to benefit more from therapy than men. According to Terrault, this is true “across the board” for different types of HCV therapy, although the gender difference is “less striking” with pegylated interferon compared to standard interferon. A couple of studies have found that interferon therapy worked better in pre-menopausal women than in men of the same age or postmenopausal women, suggesting again that estrogen may play some role in protecting women’s livers. Some research indicates that treatment does not work as well in African-Americans as it does in whites; more study is needed to determine how these race and gender effects interact in black women.

The drugs used to treat HCV cause side effects in some people. The most common side effects of interferon include headache, nausea, fatigue, loss of appetite, muscle and joint pain, and mental depression or anxiety. The most serious side effects of ribavirin are low levels of certain types of blood cells (anemia, neutropenia, and thrombocytopenia). In the population as a whole, women have higher rates of depression than men, and so may be more likely to experience this side effect; interferon is typically not recommended for people who are already experiencing major depression or other psychiatric illnesses. Interferon may worsen autoimmune conditions; the relationship between interferon and autoimmune conditions in women with HCV is an area for further study. Also, because women lose blood each month through menstruation, they are more likely than men to develop anemia (a low red blood cell count). Women taking ribavirin should have their blood cell levels monitored regularly.

Because women tend to weigh less than men, treatment dosage has been a concern. Standard interferon therapy is based on a fixed dose, and lighter-weight women may receive more of the drug than is necessary to control their HCV. Higher doses are associated with more severe side effects. Pegylated interferon, however, is dosed based on weight. People who weigh less received a lower dose, thus reducing the possibility of “overtreatment.”

HCV and Pregnancy

Many women with HCV are concerned about the risk of transmitting the virus to their babies during pregnancy or birth. Studies consistently show that the rate of perinatal or vertical transmission is low, about 5% or 1 in 20. Vertical transmission is most likely to happen when the mother has a high HCV viral load; several studies have shown that no transmission occurred when women had undetectable viral loads. Studies also show that women who are co-infected with both HCV and HIV have a higher risk (15-35%) of transmitting HCV to their infants. One British study has suggested that the risk of vertical HCV transmission may be reduced through Cesarean delivery; however, according to the Society of Obstetricians and Gynecologists of Canada, “routine Cesarean section is not recommended as a specific measure to reduce the risk of vertical transmission of HCV.”

Although HCV has been detected in breast milk in some studies, there is no indication that breastfeeding transmits the virus. Most experts do not discourage HCV-positive women from breastfeeding. But women may wish to exercise caution if their nipples are cracked or bleeding. HCV is not transmitted from mothers to children through normal household contact.

According to Terrault, who treats many women with HCV, being pregnant does not adversely affect the progression of hepatitis C. Likewise, women with HCV do not have a higher rate of pregnancy or birth complications compared to uninfected women. However, women with severe, advanced liver disease may experience difficulties during pregnancy.

Universal prenatal screening of women for HCV is not currently recommended. Babies of HCV-positive women should be tested for HCV after 12-18 months. According to the Centers for Disease Control and Prevention, most infants infected with HCV at birth have no symptoms and do well during childhood. Studies suggest that infants are more likely than adults to completely clear the virus from their bodies. HCV treatment has not been well studied in infants and children.

Ribavirin is known to cause miscarriages and birth defects, so pregnant women should not take this drug. In addition, both women of childbearing potential and men taking ribavirin should use two reliable forms of birth control during treatment and for six months after treatment ends. Most doctors also recommend that interferon should not be taken during pregnancy, because its effects on the human fetus is not well known.

Hormones and HCV

Because hormones are processed by the liver, traditionally some doctors have recommended that women with HCV should not take hormone replacement therapy (HRT) or hormonal contraceptives such as the pill. But according to Terrault, hormone doses used to be much higher than they are now, and this belief is outdated. She says that HRT should not be withheld from women with HCV if it is indicated for their overall health. Likewise, the risks of hormonal contraceptives, Terrault says, are “very low.” Some early studies suggested that women who used combined estrogen plus progesterone contraceptive pills were at higher risk for liver cancer, but a more recent study of women using newer, lower-dose pills did not find an association. Nevertheless, some doctors still recommend progesterone-based rather than estrogen-based birth control pills for women with HCV.

After menopause, when their bodies produce less estrogen, many women develop osteoporosis, or brittle bones. It is known that thinning of the bones occurs in people with liver damage. Treatment with ribavirin has also been associated with bone loss. Therefore, taking estrogen to prevent bone loss may be beneficial to women with HCV. Moderate exercise can also help maintain healthy bones, and is recommended for women with HCV unless they are feeling very ill. Avoid high dose supplements of vitamin D, which can harm the liver.

Terrault emphasizes that the effect of menopause on women with HCV should be better studied. Some women with hepatitis C and other chronic diseases have reported early menopause, and at least one study has found that liver cirrhosis is associated with reduced fertility. Terrault notes that some of her patients find it difficult to tell whether symptoms such as fatigue and depression are due to menopause or HCV. How menopause affects HCV progression and treatment is not well known, and more research is clearly needed.

Take Care of Yourself

Living with a chronic disease can be stressful. Rates of HCV are high in women who use drugs, economically disadvantaged women, and women in prison. Many women with hepatitis C face issues such as lack of access to quality health care, lack of health insurance, stigma, and discrimination.

There are several measures you can take to improve the health of your liver and your overall quality of life. Good nutrition is important for people with hepatitis C. A healthy diet is low in fat, salt, and sugar, and high in carbohydrates and fiber. Processed foods often have chemical additives, so eat less canned or frozen foods, and more fresh fruits and vegetables. Avoid high dose vitamin and mineral supplements. Some doctors recommend that people with hepatitis should drink less coffee, eat less chocolate, and avoid raw or undercooked shellfish. Avoid alcohol, which can be very harmful to the liver. The NIH recommends that people with HCV drink no more than one alcoholic beverage per day. Certain illegal or recreational drugs, prescription drugs, over-the-counter (non-prescription) medications, and herbal remedies can also damage the liver. Tell your doctor about all drugs and herbs you are taking. Because other types of viral hepatitis can be much worse in people who already have hepatitis C, anyone with HCV should ask their doctor about getting the hepatitis A and B vaccines (there is no vaccine for hepatitis C). See your doctor regularly and get checkups to monitor your liver health.

Many women with hepatitis C experience chronic fatigue and depression. Try to plan activities in advance and make realistic schedules. Pace your activities, and don’t forget to take time out for relaxation or naps. Try to maintain a realistic picture of your health. Learn to say ‘no’ to those who have unrealistic expectations of your energy level, and don’t be afraid to ask family and friends for the help you need. Meditation can be a useful tool to help reduce stress. Many people find that peer support groups with other HCV-positive people can help them cope with their disease and overcome feelings of isolation. Support groups can provide a safe space to share information and discuss the emotional issues surrounding chronic hepatitis C.

Women often put the care of their families above their own needs and neglect their own health. If you have chronic hepatitis C, don’t forget to take care of yourself!

References

  • Alter, M.J. and others. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. New England Journal of Medicine 341:556-562. August 19, 1999.
  • Hayashi, J. and others. Age-related response to interferon alfa treatment in women vs men with chronic hepatitis C virus infection: women 39 years or less of age respond better to HCV treatment than men and women older than 40 years. Archives of Internal Medicine 158(2):177-81, 1998 Jan 26.
  • Manns, M.P. and others. Autoimmunity and extrahepatic manifestations in hepatitis C virus infection. Journal of Hepatology 31 (Suppl 1):39-42. 1999.
  • Society of Obstetricians and Gynaecologists of Canada. The reproductive care of women living with hepatitis C infection. Journal of the Society of Obstetricians and Gynaecologists of Canada. October 2000.
  • Wiese, M. and others. Low frequency of cirrhosis in a hepatitis C (genotype 1b) single-source outbreak in Germany: a 20-year multicenter study. Hepatology 32(1):91-6. July 2000.

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